Hemodialysis Group Research Articles

Changes of Dissociative Properties of Hemoglobin in Patients with Chronic Kidney Disease.

Background: The ability of hemoglobin to bind and dissociate oxygen is crucial in delivering oxygen to tissues and is influenced by a range of physiological states, compensatory mechanisms, and pathological conditions. This may be illustrated by the oxyhemoglobin dissociation curve (ODC). The key parameter for evaluating the oxygen affinity to hemoglobin is p50. The aim of this study was to evaluate the impact of hemodialysis on p50 in a group of patients with chronic kidney disease (CKD). An additional goal was to assess the correlation between p50 and the parameters of erythropoiesis, point-of-care testing (POCT), and other laboratory parameters. Methods: One hundred and eighty patients (106 male, 74 female), mean age 62.5 ± 17 years, with CKD stage G4 and G5 were enrolled in this cross-sectional study. Patients were divided into two groups, including 65 hemodialysis (HD) patients and 115 patients not receiving dialysis (non-HD). During the standard procedure of arteriovenous fistula creation, blood samples from the artery (A) and the vein (V) were taken for POCT. The causes of CKD, as well as demographic and comorbidity data, were obtained from medical records and direct interviews. Results: The weekly dose of erythropoietin was higher in HD patients than in non-HD patients (4914 ± 2253 UI vs. 403 ± 798 UI, p < 0.01), but hemoglobin levels did not differ between these groups. In the group of non-HD patients, more advanced metabolic acidosis (MA) was found, compared to the group with HD. In arterial and venosus blood samples, the non-HD group had significantly lower pH, pCO2 and HCO3-. This group had a higher proportion of individuals with MA with HCO3- < 22 mmol/L (42% vs. 24%, p < 0.01). The absolute difference of p50 in arterial and venous blood was determined using the formula Δp50 = (p50-A) - (p50-V). Δp50 was significantly higher in the HD group in comparison to non-HD (0.08 ± 2.05 mmHg vs. -0.66 ± 1.93 mmHg, p = 0,02). There was a negative correlation between pH and the p50 value in arterial (pH-A vs. p50-A, r = -0.56, p < 0.01) and venous blood (pH-V vs. p50-V, r = -0.45, p < 0.01). In non-HD patients, hemoglobin levels correlated negatively with p50 (r = -0.29, p < 0.01), whereas no significant relation was found in HD patients. Conclusions: The ODC in pre-dialysis CKD (non-HD) patients is shifted to the right due to MA, and this is an additional factor influencing erythropoiesis. Hemodialysis restores the natural differences in hemoglobin's dissociation characteristics in the arterial and venous circulation.

A prospective, randomized, multicenter, open‐label trial comparing survival in subjects receiving peritoneal dialysis or conventional in‐center hemodialysis

AbstractBackgroundPeritoneal dialysis (PD) and conventional in‐center hemodialysis (HD) are treatment options for patients with end‐stage kidney disease (ESKD). However, their impact on all‐cause mortality is unclear.MethodsWe conducted a multicenter, open‐label, randomized, non‐inferiority trial to determine the effect of dialysis modality on mortality in patients with ESKD. Eligible patients were recruited from 30 sites across China and assigned to receive either PD or HD in a ratio of 1:1. The primary outcome was all‐cause mortality. Non‐inferiority was defined as the upper bound of the one‐sided 95% confidence interval (CI) for the hazard ratio (HR) being ≤1.25.ResultsA total of 414 patients with incident ESKD were randomly assigned to PD (n = 213) or HD (n = 201). During a median follow‐up of 1.7 years, 37 patients in the PD group and 31 in the HD group died, giving respective event rates per patient‐year of 0.061 and 0.071. The HR for mortality on PD in comparison with HD was 0.76 (95% CI 0.47–1.24) after adjustment for age, sex, and diabetes status, achieving the limit for non‐inferiority. There were more adverse events (p = 0.003), serious adverse events (p = 0.009), and adverse events leading to hospitalization (p = 0.003) in the PD group than in the HD group; however, there was no significant between‐group difference in adverse events leading to death or discontinuation of treatment.ConclusionsPD was non‐inferior to conventional in‐center HD in terms of survival in patients with ESKD. Our findings underscore the need for shared decision‐making between physicians and patients regarding the selection of dialysis modality.Trial registrationRegistered at ClinicalTrials.gov (NCT01413074).

Reduced functional connectivity induced by longitudinal alterations of structure and perfusion may be associated with cognitive impairment in patients on maintenance hemodialysis.

Hemodialysis (HD) leads to cognitive impairment; however, the pathophysiology of maintenance HD remains unclear. This study aimed to investigate the longitudinal alterations in gray matter volume (GMV) and cerebral blood flow (CBF) in patients on HD at follow-up compared with baseline, examine the alterations in functional connectivity (FC) by defining co-changed brain regions as seed points, and investigate the correlation between the co-changed brain regions and neuropsychological test scores. Twenty-seven patients with HD and 30 healthy controls were enrolled in this study. All participants underwent high-resolution T1-weighted imaging, arterial spin labeling, and functional MR imaging to measure GMV, CBF, and FC. The patients on HD were assessed at baseline and 3years subsequently. The right and left medial superior frontal gyrus (SFGmed.L) exhibited significantly lower GMV and CBF in patients on HD at follow-up compared with baseline and lower FC between the SFGmed.L and left middle temporal gyrus (MTG.L). FC between the SFGmed.L and MTG.L was positively correlated with neuropsychological test scores in the HD group at follow-up. Reduced GMV and CBF may result in decreased FC between the SFGmed.L and MTG.L, which may be associated with cognitive impairment in patients on maintenance HD. Our findings provide unique insights into the pathological mechanisms of patients on maintenance HD with cognitive impairment.

Differences in Nutritional Status and Quality of Life in Hemodialysis Patients Compared to CAPD

Background: Patients with chronic kidney disease who undergo hemodialysis and CAPD (Continous Ambulatory Peritoneal Dialysis) modalities often experience disturbances in nutritional status and quality of life. The condition is affected by the chosen modalities and duration. Aim: This study assesses the differences in nutritional status and quality of life in individuals undergoing hemodialysis therapy with a duration of 4-hour, hemodialysis with a duration of 5-hour, and CAPD in order to determine the best modalities for patients with chronic kidney disease. Methods: Data were collected with cross-sectional from patients with chronic kidney disease at the hemodialysis polyclinic at RSUD dr. Saiful Anwar Malang, Panti Nirmala Hospital Malang, Wava Husada Kepanjen Hospital, and the CAPD polyclinic at RSUD dr. Saiful Anwar Malang. Classified into CAPD group, 4-hour hemodialysis group, and 5-hour hemodialysis group. Assessment with a questionnaire consisting of the patient’s baseline characteristics, subjective global assessment (SGA), and SF-36 are used to assess and analyze differences in nutritional status and quality of life of patients with chronic kidney disease against the selected dialysis modality. Results: The physical health of the 5-hour hemodialysis group showed significant results compared to the 4-hour hemodialysis and CAPD (p &lt;0.05). Mental health in the 5-hour hemodialysis procedure showed significant results compared to the 4-hour hemodialysis and CAPD (p &lt;0.05). The nutritional status of 5-hour of hemodialysis was better than 4-hour of hemodialysis and CAPD (p&lt;0.05). Conclusion: Hemodialysis with a duration of 5-hour has a better nutritional status and quality of life compared to a duration of 4-hour or CAPD.

#1353 Apathy and fatigue in patients treated with haemodialysis and peritoneal dialysis

Abstract Background and Aims Apathy is a distinct syndrome manifesting with a loss of interest in social or emotional situations, lack of sense of purpose, low energy levels and detachment from life and personal events. Previous studies showed that apathy is associated with vascular impairment and consequent cognitive dysfunction, reduced quality of life and increased hospitalization, institutionalization, healthcare costs and death. So far there has been little research on the prevalence of apathy among dialysis patients although this population could be considered at risk for this condition due to increasing age, and disease and treatment burden. Fatigue is also common in dialyzed patients and impacts daily living, impairs the quality of life, increases the risk of cardiovascular events and negatively influences survival. This study aimed to explore the link between apathy and fatigue among hemodialysis (HD) and peritoneal dialysis (PD) patients. Method We conducted a cross-sectional cohort study which included 75 HD (57.3% male, median age 64 years) and 62 PD patients (48.4% male, median age 61 years) from two dialysis centres. Apathy status was assessed by the Apathy Evaluation Scale (AES) by Starkstein. Fatigue was evaluated with the Functional Assessment of Chronic Illness Therapy (FACIT) scale. AES score of 14 and higher denotes the presence of apathy, while a FACIT score of less than 30 indicates severe fatigue. Demographic, clinical and laboratory data were obtained by a focused questionnaire and from electronic medical records. Data were analyzed with T-test, Hi-square, ANOVA and Pearson correlation as applicable. Results HD patients were significantly longer on dialysis than PD patients (p=0.046). Apathy was more frequent among PD patients compared to the HD group (64.5% vs 48%), but the difference was not statistically significant (p = 0.053). Severe fatigue was more frequent in the HD group (33.8% vs 27.4%), but the difference was not statistically significant (p = 0.424). Elderly patients had a higher prevalence of apathy in both HD (70.3% vs 29.7%, p&amp;lt;0.001) and PD groups (84.2% vs 16.3%, p = 0.008), and a significantly higher prevalence of severe fatigue in the HD group (68% vs 32%, p = 0.017). Among HD patients higher education level was significantly associated with higher FACIT and lower apathy scores (p = 0.002 and p = 0.001 respectively). HD patients taking psychotropic medication had significantly lower FACIT (27.2±13.5 vs 35.0 ± 11.9, p = 0.03). Also, the presence of apathy was significantly associated with lower hemoglobin levels (101.7±9.7 vs 110.3±11.2, p = 0.001), red blood cells count (3.2±0.2 vs 3.5±0.6, p = 0.004), lower serum creatinine (900.0±149.1 vs 1001.5±266.4, p = 0.047) and lower Kt/V (1.35±0.22 vs 1.49±0.24, p = 0.008) in the HD group, while PD patients with severe fatigue had significantly higher creatinine levels (796.7±176.9 vs 646.4±200.0, p = 0.009). Gender, dialysis vintage, primary renal disease, and comorbidities were not significantly associated with either apathy or fatigue in either group of patients. Apathy and fatigue were significantly correlated in both the HD (p = 0.04) and the PD (p = 0.001) groups. Conclusion Apathy is a highly prevalent and often overlooked condition among dialyzed patients regardless of dialysis modality. Longitudinal studies should explore whether apathy is a causative factor for fatigue in these populations.

#2594 Patient-reported inter- and intradialytic symptoms in HD &amp; HDF patients

Abstract Background and Aims Patients on hemodialysis (HD) experience a wide range of symptoms during and between dialysis that negatively affect their well-being. Addressing these symptoms, particularly from the patient's perspective, is a crucial component in the treatment. Our findings suggest a beneficial effect of hemodiafiltration (HDF) over hemodialysis (HD) on mortality and quality of life. This study aimed to investigate the differences in symptom severity between patients on HD and HDF. Method Patient-reported outcomes data of 1264 hemodialysis patients were extracted from CONVINCE, an international randomized controlled trial comparing high-dose hemodiafiltration with high-flux hemodialysis, including baseline and quarterly follow-up data up to 24 months. Symptoms were assessed using the CONVINCE peridialytic symptoms questionnaire covering inter- as well as intradialytic symptoms (see Table 1) with items scored between 0-100, higher scores indicating fewer symptoms. Prevalence and scores of all inter- and intradialytic symptom items at baseline and during follow-up visits were assessed and compared between HD and HDF groups. The association of changes of symptom scores over time with dialysis modality (HD vs. HDF) was assessed by Mixed Models for Repeated Measures (MMRM). Results MMRM analyses showed no significant main effects of dialysis modality on symptoms at the p &amp;lt;.05 level. However, descriptive statistics and plots indicated higher scores for most symptoms in the HDF group. The highest score differences between HDF and HD group over all timepoints were found for itchy skin (2.09 [95% CI −0.09-4.26]), numbness in hands or feet (2.03 [95% CI −0.22-4.28]), being washed out or drained (1.88 [95% CI −0.23-3.99]) and lack of appetite (1.73 [95% CI −0.03-3.50]). Plots for these symptoms can be found in Fig. 1. Furthermore, no significant interactions were found between dialysis modality and time, indicating that the rate of change in symptom scores did not differ significantly between the HDF and HD group. Conclusion No statistically significant differences in patient-reported symptoms between HDF and HD patients were found. We may not have the granularity of data to fully explore factors which may have contributed to the positive effects of HDF that have been reported previously. This might be due to the method of symptom assessment used or specific issues with perception of symptom burden. Our results highlight the complexity of symptom management in dialysis patients and underscore the need for future symptom assessments to allow for personalized treatment strategies that further optimize patient care.

#1874 Comparative analysis of rehabilitation outcomes in hospitalized hemodialysis vs. non-hemodialysis patients: a retrospective cohort study

Abstract Background and Aims The hospitalization rate of patients undergoing hemodialysis (HD) is high, due to complications related to renal failure and hemodialysis treatment. Therefore, it is crucial to provide rehabilitation for hospitalized HD patients to improve their activities of daily living (ADL) and physical functions, so as to enable them to be discharged home, resume outpatient dialysis, and avoid re-hospitalization. However, the effectiveness of rehabilitation to improve the ADL and physical functions may differ between hospitalized patients undergoing HD (HD patients) and hospitalized patients not undergoing HD (non-HD patients), depending on their pathological conditions and influence of the HD treatment. The aim of the present study was to compare the outcomes of rehabilitation between hospitalized HD patients and non-HD patients. Method This was a retrospective cohort study. The inclusion criteria were hospitalized patients who received rehabilitation between April 2017 and February 2023. The exclusion criteria were patients who discontinued rehabilitation, were transferred to other hospitals, or died during the rehabilitation period. Rehabilitation consisted of physical therapy and/or occupational therapy provided six times a week, for both hospitalized HD and non-HD patients. The rehabilitation program comprised balance training, aerobic exercises, resistance training, and ADL training to prepare the patients for discharge to their homes. We measured several outcomes in the study, including the daily duration of rehabilitation (min/day), length of hospital stay (days), Barthel index (BI), as the ADL index, at the time of admission and discharge, grip strength and isometric knee extension strength (IKES) as muscle strength indices, and the 10-meter walking speed, timed up and go test (TUG), and short physical performance battery (SPPB) as mobility function indices. For the statistical analysis, missing values were completed by using multiple imputation methods. The inverse probability weighting (IPTW) method was used to match the HD group and non-HD group to adjust for confounding factors. The outcomes between the groups were then compared using a generalized linear model analysis. All procedures in the present study were conducted with the approval of the ethics committee of Seirei Christopher University. Results Of 1002 patients who were registered for the study, 100 patients who discontinued rehabilitation, were transferred to other hospitals, or died were excluded, and the data of the remaining 902 patients (765 of the non-HD group and 137 of the HD group) were included in the analysis in this study. The results of the generalized linear model analysis revealed a lower daily duration of rehabilitation [43.3(0.6) vs. 38.8(1.2) min/day, p=0.0003] and longer length of hospital stay [48.5(0.5) vs. 58.1(2.3) days, p=0.0108] in the HD group. In addition, the 10-meter walking speed [0.75(0.02) vs. 0.66(0.03) m/s, p=0.003] and scores on the TUG [20.8(0.7) vs. 24.3(1.0) sec, p=0.0021] and SPPB [6.3(4.57) vs. 4.7(0.6) points, p=0.0415] at discharge were also significantly lower in the HD group as compared with the non-HD group. There was no difference in the ability for ADL or muscle strength at discharge between the two groups. Conclusion This study was the first to demonstrate a lower daily duration of rehabilitation and longer hospital stay in hospitalized HD patients. Furthermore, rehabilitation had a lower impact on the mobility indices in HD patients as compared with non-HD patients. Although there was no difference in the ability for ADL or muscle strength at discharge between the two groups, HD patients exhibited a significantly lower ability for mobility functions, including a lower gait speed and lower scores on the TUG, and SPPB assessments. Therefore, rehabilitation efforts in HD patients need to be improved by securing more time for inpatient rehabilitation and promoting mobility function improvement.

#2309 Understanding the caregiver experience: a comparison between patients undergoing hemodialysis and conservative care management

Abstract Background and Aims Elderly patients with Advanced Chronic Kidney Disease (ACKD) experience a high rate of physical and emotional burden, whether they choose dialysis or not. However, little is known about the challenges faced by family and throughout the disease. This study aimed to evaluate how caregivers of ACKD patients over 75 years-old (yo) perceive and cope with the disease. Method We performed telephone interviews with family members (FM) or caregivers of ACKD patients over 75 yo, undergoing Conservative Kidney Management (CKM) or hemodialysis (HD). The interviews were recorded and analyzed by two independent investigators. The interview guide was based on literature review and the authors’ clinical experience. It comprised 12 questions focused on the medical team support and communication, the caregivers’ perception of their relatives’ quality of life (QoL), the caregivers’ burden, and the perception of advance care planning. Results A total of 22 FM were interviewed, 11 from patients undergoing HD and 11 undergoing CKM. All caregivers were family members: 90.9% sons/daughters and 9.1% spouses. 54.5% of patients on CKM were females, with a mean age of 88.9 ± 5.0 yo; 36.4% of patients on dialysis were female, with a mean age of 82.1 ± 4.8 yo. Regarding team communication, FM of patients on CKM were more aware of the prognosis of kidney disease and felt more involved in the decision-making process (Table 1). All FM of both groups reported medical team support for their relatives. Concerning QoL, all FM of CKM patients mentioned symptom control, compared to 81.8% in the HD group. Additionally, 27.3% FM of CKM felt ACKD deprived their relatives of their liberty, versus 72.7% in the HD group. No caregiver recognized a high burden of the disease. Regarding advance care planning, a majority of FM of HD patients (81.8%) desired open discussions, versus 45.4% of the CKM. Some supportive/illustrative quotes of the FM answers are shown in Table 1. Conclusion Caregivers are vital in the support and care of any patient with a chronic illness, especially ACKD, and their burden and awareness about the disease must always be considered. The approach to patients in CKM is essentially palliative, prioritizing QoL and symptom control. These patients are regularly evaluated by multidisciplinary teams with training in palliative care, which promotes shared decision-making and more efficient communication skills about disease and prognosis to the patient and family. Unfortunately, palliative care is not yet well established in patients undergoing HD, which may explain the results and answers given by FM. It is crucial to improve support for caregivers of all ACKD patients, preferably with a multidisciplinary team.

#1067 The impact of hemodialysis (HD) versus hemodiafiltration (HDF) on the effect of intradialytic exercise: a multicentre cohort study

Abstract Background and Aims Diminished physical function in HD patients is a critical issue, necessitating strategic approaches to enhance the efficacy of exercise therapy. The differential impacts of HD and HDF on solute clearance, albumin loss, uremic conditions, and malnutrition could influence the success of exercise interventions. Presently, empirical evidence for this is lacking. This investigation explores how HD and HDF modalities influence the efficacy of exercise therapy administered during dialysis sessions. Method This study encompassed intradialytic resistance exercises, involving 414 patients with end-stage renal disease across 10 centers. Participants were voluntarily enlisted in an exercise regimen during their dialysis sessions. The intradialytic regimen comprised stretching and four types of resistance exercises utilizing elastic tubes, conducted thrice weekly over six months. Parameters such as 10-meter walking speed, knee extensor muscle strength, serum albumin levels (Alb), normalized protein catabolic rate (nPCR), and Creatinine Generation Rate (%CGR) were assessed pre-and post-intervention. Statistical analysis included propensity score matching to adjust for baseline characteristics, segregating patients into HD and HDF cohorts. Changes in the aforementioned indicators before and after intervention (Δ) were calculated. Analytical methods included paired t-tests for within-group comparisons and independent t-tests for between-group comparisons of Δ values. A 5% risk threshold was established for statistical significance. Ethical clearance was obtained from the Seirei Christopher University Ethics Committee. Results A propensity score matching yielded 70 matched pairs. There were no significant differences in baseline subject characteristics after propensity score matching. Within-group analyses in the HD group revealed significant improvements in 10-meter walking speed (1.42 ± 0.41→1.60 ± 0.46 m/s, p = 0.000), knee extensor strength (44.3 ± 14.7→49.6 ± 13.8%, p = 0.000), and a reduction in Kt/V (1.69 ± 0.32→1.64 ± 0.32, p = 0.006) after six months. The HDF group significantly enhanced 10-meter walking speed (1.54 ± 0.40→1.72 ± 0.40, p = 0.000), knee extensor muscle strength (51.7 ± 17.1→57.4 ± 17.7%, p = 0.000), nPCR (0.88 ± 0.15→0.94 ± 0.18, p = 0.009), and %CGR (106.3 ± 23.2→112.9 ± 25.2, p = 0.002) (pre to post value, respectively). There are no significant differences in other variables between pre- and post-values in each group. Comparative analysis between groups demonstrated a significantly lower ΔAlb (HD 0.04 ± 0.24 HDF −0.05 ± 0.27, p = 0.045)and a higher 7, p =0(HD 1.47 ± 18.2 HDF 6.65 ± 17.2, p = 0.004)in the HDF group compared to the HD group. Conclusion The study demonstrated a notable HDF group improvement in %CGR, an indicator of muscle mass, despite a decrease in albumin levels. This suggests that albumin loss due to HDF minimally affects the augmentation of physical function. The findings suggest integrating exercise therapy with HDF may positively influence protein consumption and muscle mass enhancement.

#1853 Comparative analysis of atherosclerotic risk factors in dialysis patients

Abstract Background and Aims Prevailing studies indicate a correlation between elevated serum phosphate levels and an augmented incidence of cardiovascular events. In patients undergoing dialysis, hyperphosphatemia contributes to vascular and valvular calcifications. This study analyzes the interrelation of phosphate levels, inflammatory markers, and additional risk determinants in the development of carotid artery atherosclerosis in individuals receiving peritoneal dialysis (PD) versus hemodialysis (HD). Method A cohort of 39 PD and 53 HD patients were recruited, all undergoing stable renal replacement therapy (RRT) for three to thirty-six months. B-mode ultrasonography assessed the carotid artery intima-media thickness (CIMT) and detected plaque and calcification occurrences. Patients were specified as having atherosclerosis when CIMT was greater than 1 cm, and the presence of plaque was identified. Logistic regression analysis was employed to discern the connection between potential risk factors and the incidence of atherosclerosis. Results The study encompassed 92 participants, 61% undergoing HD and an average age of 53.4 years (standard deviation ± 14.5 years). The tubulo-interstitial disease was the predominant initial pathology, followed by chronic glomerulonephritis and nephroangiosclerosis. Diabetic nephropathy was identified as the etiology of end-stage renal disease (ESRD) in 23.1% of PD and 11.4% of HD subjects (p = 0.047). Notably, PD patients showed better residual renal function (RRF) (p &amp;lt; 0.001), urine volume over 24 hours (p &amp;lt; 0.001), and C-reactive protein (CRP) (p = 0.047), alongside diminished phosphate (p = 0.01), parathyroid hormone (PTH) (p &amp;lt; 0.05), alkaline phosphatase (p &amp;lt; 0.05), and albumin levels (p &amp;lt; 0.001) relative to their HD counterparts. Atherosclerosis prevalence was 66.3%, inclusive of the entire diabetic cohort. The incidence of atherosclerosis did not significantly diverge between PD and HD groups [56.4% vs 73.6% in HD, respectively]. Atherosclerotic patients were older (p &amp;lt; 0.001) and exhibited heightened phosphate levels (p = 0.012), pulse pressure (p = 0.01), and calcium index (Ci) (p = 0.034). Multiple regression analysis elucidated age, phosphate, RRF, PTH, pulse pressure, diabetes, and HD modality as autonomous factors linked to atherosclerosis. Conclusion Beyond conventional risk factors like age and diabetes, metabolic disorders arising from renal insufficiency were identified as contributing to atherosclerotic development. Multivariate analysis identified phosphate, RRF, and pulse pressure (PP) as independent atherosclerotic risk factors. The HD modality carried an elevated atherosclerotic risk compared to PD. It was thought that preserving RRF in PD patients would improve phosphate regulation and maybe even improve endothelial function, explaining the differences found.

#1399 Hemodiafiltration or haemodialysis for kidney failure: updated systematic review and individual participant data meta-analysis

Abstract Background and Aims A recent large European randomised controlled trial (RCT) showed a 23% reduction in all-cause mortality in favour of high dose haemodiafiltration (HDF) compared to high flux haemodialysis (HD). Several reactions critically questioned the main outcome and subgroup results and thereby its implications. Implications, however, should not be viewed based on results of one trial, but rather on the combined available evidence. Therefore, we set out to update our previous 2016 individual patient data meta-analysis (IPA-MA). An IPA-MA was chosen over an aggregated data meta-analysis as it allows more powerful and uniformly consistent analyses of subgroups and outcomes. Method The study was conducted according to PRISMA-IPD guidelines. We performed searches in MEDLINE, Embase and CENTRAL to identify RCTs in kidney failure patients with at least one year follow-up after randomisation, comparing on-line HDF with HD on mortality outcomes. Investigators were invited to share participant level data. The primary outcome was all-cause mortality. Secondary outcomes were cause-specific death (cardiovascular, only cardiac, only non-cardiac, infection-related, sudden death). We ran Cox proportional hazards models using intention to treat samples with a random effect for study, reporting hazard ratios (HR) and 95% confidence intervals (95% CI), overall and stratified by several predefined patient characteristics. Also, we ran Cox models using HDF patient data to estimate relations between achieved convective volume and mortality outcomes. Results Data from five European RCTs (i.e. ESHOL, CONTRAST, French HDF Study, Turkish HDF Study, and CONVINCE) were included, comprising 4153 patients. After a median follow-up of 30 months (Q1-Q3: 24-36), death from any cause occurred in 558 patients (27.2%) in the HD group and in 477 patients (23.3%) in the HDF group (HR: 0.84; 95% CI: 0.74 to 0.95). There was no evidence for a differential effect across subgroups. Cause specific analyses showed, compared to the HD, a lower risk of cardiovascular death in the HDF group (HR: 0.78; 95% CI: 0.63 to 0.96), which seemed to be driven by a lower risk for cardiac death (HR: 0.67, 95% CI: 0.50 to 0.89). The largest survival benefit was found for patients achieving a convective volume of 23 L or above, with a multivariable adjusted HR of 0.63 (95% CI: 0.50 to 0.79) for all-cause death, of 0.58 (95% CI: 0.40 to 0.85) for cardiovascular death and of 0.51 (0.28 – 0.93) for infection related death. The relation between achieved convection volume and mortality outcomes seemed gradual: the higher achieved the volume, the lower the risk compared to HD. Conclusion The combined available individual patient data from RCTs indicate that on-line HDF treatment improves survival with, at present, no clear differences across patient subgroups, when identified based on single characteristics. Our finding “the higher dose of HDF achieved, the lower the risk” seems congruent with that reported previously from observation studies.

#2771 Peritoneal dialysis after kidney graft loss … and now, what?

Abstract Background and Aims The evolution of peritoneal dialysis (PD) as renal replacement therapy (RRT) after graft loss is not well defined. Method Retrospective analysis of the Andalusian Renal Registry of patients who received their first kidney transplant (KT) in Andalusia (Spain) and returned to dialysis between 1978-2023. Patients who lost follow-up and those who underwent preemptive re-KT were excluded of the study. We compared clinical characteristics and evolution between those who started hemodialysis (HD) and peritoneal dialysis (PD) after graft loss. Secondly, we analyzed technique and patient survival in those who started PD post-KT versus patients on PD as their first renal replacement therapy (RRT) We performed multivariate analysis for PD technique and patient survival risk factors using Cox regression. Results During this period, we followed 11868 KT recipients in Andalusia. Of these, 3148 (26.52%) lost the graft: 2768 started HD and 298 PD. 82 patients underwent preemptive re-KT. Patients who returned to DP were younger (p &amp;lt; 0.001) and glomerulonephritis as cause of chronic kidney disease (CKD) was more frequent (p = 0.019). The pre-KT RRT was HD in 96.3% of patients starting HD post-KT and PD in 48.3% of patients who returned to PD after KT (p &amp;lt; 0.001). Survival of patients in the HD group was lower than those who started PD (p = 0.026). In the multivariate analysis, older age when dialysis restarted, male sex and diabetes were risk factors for patient death and not the type of dialysis. When comparing only the post-KT PD group (n = 298) versus patients on PD as their first RRT (n = 5312), patients on the first group were younger (57.1 vs. 41.9; p &amp;lt; 0.001) and time on PD was longer (24.4 vs. 19 months; p &amp;lt; 0.001). The causes of PD drop-out also varied between groups (p &amp;lt; 0.001). During this period, 269 post-KT PD patients left the technique mainly due to re-KT (34.3%) and in the PD group as the first RRT, there were 4919 technique drop-outs, mainly due to transfer to HD (35.3%) and death (30%). The percentage of peritonitis was higher in the post-KT PD group, although without significant differences (post-KT PD 27.9% vs. PD as first RRT 23.25%; p = 0.061). Survival of the DP technique in post-KT PD group was 78.2% at 1 year and 38.5% at 5 years, and 77.7% and 42.1% respectively in the DP group as the first DP RRT (p = 0.059). In the multivariate analysis, patient age and diabetes as a cause of CKD, behaved as risk factors for patient survival. Conclusion Almost half of the patients starting PD after KT had been on PD prior to transplantation. They tend to have more peritonitis although survival of the technique and complications were very similar to those observed in patients on PD as first RRT.

#605 Shared decision-making intervention regarding dialysis modality in patients with CKD stage 5

Abstract Background and Aims Patients with kidney failure must make complicated decisions about the dialysis modalities used either at home or in-hospital. Different options have varying levels of impact on patients’ physical and psychological conditions and their social life. The purpose of this study was to evaluate the implementation of an intervention designed to achieve shared decision making (SDM) in patients’ options for dialysis. Method SDM was performed after consent was written for stage 5 chronic kidney disease patients before dialysis, and 435 cases were performed in 408 patients from December 16, 2019 to June 30, 2021. Among these, 101 patients were compared by SDM measurement scale, patient satisfaction, disease recognition scale survey, and dialysis method. Results The average age of participants was 56 years, with a gender composition of 55 males (54.5%) and 46 females (45.5%). Following SDM, the final dialysis methods decided upon by patients and clinicians were peritoneal dialysis (67 patients, 66.3%), hemodialysis (22 patients, 21.8%), and kidney transplantation (1 patient, 1.0%). Looking at the items, “My doctor and I chose treatment together” (94% in the PD group, 87.5% in the HD group, P = .012) and “My doctor and I agreed on a course of treatment” (97% in the PD group, 81.3% in the HD group, P = .058), the group of patients that selected treatment with PD had a significantly higher percentage of positive answers of 4 points or higher in comparison to the group of patients that selected HD Conclusion Among participating patients, SDM was effective when used to decide on dialysis treatment, and patients were satisfied with the dialysis method decision process. On the disease awareness scale, those who participated in this project had relatively high positive and low negative perceptions, so it can be concluded that SDM was relatively effective. The implementation of SDM was helpful in selecting patients’ best dialysis methods, and SDM scale results were higher in the peritoneal dialysis group than in the hemodialysis group.

#1530 Studying parenteral nutrition in patients with dialysis stage chronic kidney disease

Abstract Background and Aims Hemodialysis is associated with high rates of morbidity and mortality, as well as poor quality of life. Changes in nutritional status and loss of protein and energy are important indicators of these risks. Maintaining optimal nutritional status in hemodialysis patients is an important but sometimes overlooked aspect of treatment. In some cases, intradialytic parenteral nutrition is possible, but lack of knowledge about the practical aspects of administration is rarely discussed. The purpose of our study was to study the age-related characteristics of the nutritional status in patients with CKD of the dialysis stages who are on parenteral nutrition. Method The study included 40 patients with stage C5 CKD. Glomerular filtration rate (eGFR) was estimated using the CKD-EPI formula (2011) [11]. Anthropometric data were studied: height, weight, body mass index (BMI), mid-thigh circumference and mid-upper arm circumference, as well as laboratory data: urea, creatinine, electrolytes, albumin, total protein, hemoglobin. All patients underwent instrumental research methods: ECG, EchoCG. The patients were divided into 2 groups – with and without PEM. Statistical data processing was carried out according to standard methods using a computer program package. Results Total body water (TBW) (P = 0.026) and triceps skinfold thickness (P &amp;lt; 0.05) were higher in the hemodialysis group. BMI and other anthropometric parameters showed no significant differences between the two groups. Total caloric intake (P &amp;lt; 0.05) and total cholesterol (P &amp;lt; 0.05) were higher in patients with PEM. Intake of other nutrients, including proteins, lipids, microelements and vitamins, did not show significant differences between the two groups. Only 24% of patients were malnourished. Triglyceride levels were higher in non-malnourished patients, but HDL levels were higher in malnourished patients. Some anthropometric indicators were significantly higher in patients not suffering from PEM. It is worth noting that malnourished patients consumed more calories and nutrients, including proteins, plant lipids, animal lipids and carbohydrates. Conclusion Compared with malnutrition patients and non-malnutrition patients, several anthropometric parameters, including subiliac skinfold thickness and MAC, were significantly lower in the malnutrition group. These values can be measured using simple methods and are used as a useful method for assessing malnutrition. Interestingly, patients with malnutrition and lower BMI albumin actually consumed more calories and nutrients from food. This means that malnutrition in dialysis patients is not simply caused by low food intake.

#867 Calciprotein particles and phosphorus in conventional and extended-hours hemodialysis

Abstract Background and Aims Extended-hours hemodialysis (HD) has better clinical outcomes than conventional HD. Previous studies have shown that a prolonged dialysis treatment time is associated with lower serum phosphorus levels, but the impact of extended-hours HD on calciprotein particles (CPP) is unknown. We investigated whether extended-hour HD and conventional HD have varying effects on blood levels of CPP and phosphorus, which have been identified as the main pathogenic molecules for vascular calcification. Method We performed a cross-sectional study of patients with extended-hours HD or conventional HD between January and March 2020. Blood CPP levels were measured in plasma and serum predialysis samples using a previously reported "gel filtration method". Linear and nonlinear associations between CPP and serum phosphorus levels were examined across dialysis modalities. Results A total of 382 participants (185 with extended-hours HD and 197 with conventional HD) were included in the analysis. The median age of participants was 71 years, 65% of the patients were men, and the mean phosphorus level was 5.4 mg/dL. Extended-hours HD was associated with lower plasma CPP levels (Extended-hours HD vs Conventional HD; 40,018 AU vs 75,728 AU) and serum CPP levels (Extended-hours HD vs Conventional HD; 66,524 AU vs 100,812 AU), regardless of similar serum phosphorus levels. Multivariable linear regression analysis showed that extended-hours HD was associated with lower natural logarithmic plasma CPP levels: -0.64 (95% CI: -0.74 to -0.55). Restricted cubic spline function indicated that extended-hours HD was associated with lower plasma CPP levels across levels of serum phosphorus, with significant differences observed between groups, especially in hyperphosphatemic conditions (P for interaction &amp;lt;0.01). Conclusion The patients with extended-hours HD had lower CPP levels than those with the conventional HD group despite no significant differences in serum phosphorus levels, which may contribute to better clinical outcomes in patients on extended-hours HD.

#321 Hemodiafiltration for ESRD patients

Abstract Background and Aims This systematic review and meta-analysis were designed to determine the effect of hemodiafiltration (HDF), or hemofiltration (HF) compared to hemodialysis on the prognosis of end-stage renal disease (ESRD) patients. Method PubMed, Embase, and Web of Science were searched for published studies from reception to 18 September 2023, and updated search on October 15, 2023. Randomized clinical trials (RCTs) or cohort studies evaluated prognosis of hemodiafiltration, or hemofiltration compared to hemodialysis in patients with ESRD were included. Data was synthesized based on heterogeneity with corresponding model selected, and trial sequential analyses were conducted. The primary outcome was all-cause mortality, and secondary outcome was cardiovascular mortality and dialysis adequacy. Outcomes were reported as relative risk (RR), hazard ratio (HR), or mean difference (MD) with a 95% confidence interval (95% CI). Results There were 26 RCTs, 10 cohort studies, and total of 36 articles included in the meta-analysis. Pooled results of RCTs showed a statistically significant difference in all-cause mortality between HDF/HF group and standard hemodialysis group (RR = 0.86; 95% CI 0.78-0.96; I2 = 29%; Fig. 1). Trial sequence analysis (TSA) showed that the all-cause mortality curve crossed the traditional and TSA boundaries, but it was not yet as informative as desired. Subgroup analysis found that ESRD patients treated with hemodiafiltration had a 13% lower risk of death (RR = 0.87; 95% CI 0.78-0.97; Fig. 1) with no heterogeneity (I2 = 0%). In contrast, the effect of hemofiltration on mortality risk in ESRD patients was not significant (RR = 0.70; 95% CI 0.39-1.29; Fig. 1). A similarly statistically significant difference in cardiovascular mortality (RR = 0.747; 95% CI 0.607-0.917; I2 = 0%; Fig. 2) for RCTs. In addition, HDF/HF treatment was significantly associated with improved dialysis adequacy (Assessed by Kt/V) in ESRD patients (MD: 0.09; 95% CI 0.01-0.17; I2 = 96%). The combined results of cohort studies showed a 28.6% reduction in mortality risk in ESRD patients treated with HDF (HR = 0.714; 95% CI 0.575-0.886; I2 = 84%; Fig. 3), with an HR for cardiovascular mortality of 0.708 (95% CI 0.604-0.829; I2 = 0%; Fig. 4). Conclusion Overall, HDF/HF was associated with reduced all-cause mortality and cardiovascular mortality in patients with ESRD and contributed to improved dialysis adequacy.

Treatment Patterns for End-Stage Kidney Failure in Patients With Systemic Lupus Erythematous.

This study aims to examine the treatment patterns of end-stage kidney disease (ESKD) among SLE patients and to compare the outcome of hemodialysis (HD) and peritoneal dialysis (PD). SLE patients identified from the national administration dataset in 2005-2021 were linked to the Australia and New Zealand Dialysis and Transplant Registry to identify ESKD cases. The adjusted odds ratio of having PD instead of HD as the first treatment for ESKD for Asian, Māori, and Pacific compared with European/others was estimated with the logistic regression model. The adjusted hazards ratio of all-cause mortality for patients having PD first compared with HD first was calculated. Two hundred ten ESKD patients with SLE were identified. Two thirds (137/210) of the ESKD patients had HD as the first treatment, and one third (68, 32.4%) had PD first. Around 60% of Asian patients had PD as the first treatment, compared with 30% in other ethnic groups. The adjusted odds ratio of having PD as the first treatment for Asian patients compared with European/others was 3.00 (95% confidence interval, 1.16-7.73). The adjusted hazards ratio of all-cause mortality for patients in the PD group compared with the HD group was 0.60 (95% confidence interval, 0.37-0.97). Asian patients with ESKD were more likely to have PD as the first treatment. The optimal dialysis type for ESKD patients with SLE might be different from ESKD patients caused by other diseases. ESKD patients with SLE receiving PD first had superior outcomes than patients receiving HD first.

Quality of life and sleep, depression, family functioning, and marital adjustment in patients on hemodialysis and peritoneal dialysis.

End-stage renal disease is different from other chronic diseases that the treatment method is as difficult. Our aim in this study was to compare marital adjustment, sexual functions and family functioning between hemodialysis (HD) and peritoneal dialysis (PD) patient. A total of 21 HD and 27 PD patients were included. Beck Depression Inventory (BDI), Short Form-36 (SF-36), Pittsburgh Sleep Quality Index (PSQI), Arizona Sexual Experiences Scale (ASEX), Golombok-Rust Inventory for Sexual Satisfaction (GRISS), Marital Adjustment Test (MAT) and Family Assessment Device (FAD) were applied. BDI scores were significantly higher in HD patients (p < 0.001). According to FAD problem solving (p < 0.001), communication (p = 0.00) and general functioning scores (p = 0.04) were higher in PD. The rate of poor sleep quality was 44.4% in the PD group, and 66.7% in HD group (p = 0.12). General health (p = 0.04), vitality (p < 0.001), mental health (p = 0.00) and social functioning (p = 0.00) scores were lower in HD patients. HD patients are at high risk for psychiatric disorders due to the treatment modality. These patients should be monitored carefully and consultation-liaison services should be increased.

Association of calciprotein particles with serum phosphorus among patients undergoing conventional and extended-hours haemodialysis.

Extended-hours haemodialysis (HD) is associated with better clinical outcomes than conventional HD. We investigated whether extended-hours HD and conventional HD have varying effects on blood levels of calciprotein particles (CPPs) and phosphorus, which have been identified as major pathogenic molecules for vascular calcification. Patients who underwent conventional or extended in-centre daytime HD between January and March 2020 were included. Plasma CPP levels, representing only secondary CPPs (CPP-II), were measured in pre-dialysis samples. Linear and non-linear associations between CPPs and serum phosphorus levels were examined across dialysis modalities. A total of 382 participants (185 undergoing extended-hours HD and 197 undergoing conventional HD) were included in the analysis. The median age of participants was 71years, 65% of the patients were men and the mean phosphorus level was 5.4mg/dl. Plasma CPP (CPP-II) levels were lower in the extended-hours HD group than in the conventional HD group [40018(arbitrary units) AU versus 75728AU; P<.01]. Multivariable linear regression analysis showed that extended-hours HD was associated with lower natural logarithmic plasma CPP (CPP-II) levels: -0.64 (95% confidence interval -0.74 to -0.55). A restricted cubic spline function indicated that extended-hours HD was associated with lower plasma CPP (CPP-II) levels across levels of serum phosphorus, with significant differences observed between groups, especially in hyperphosphataemic conditions (P for interaction <.01). The extended-hours HD group had lower CPP levels than the conventional HD group despite no significant differences in serum phosphorus levels, which may contribute to better clinical outcomes in patients on extended-hours HD.

Astragalus membranaceus Treatment and Clinical Care Pathways for Inflammation and Oxidative Stress Management in Hemodialysis

This study aimed to investigate the effects of Astragalus membranaceus (AM) treatment combined with clinical care pathways (CCP) on inflammation and oxidative stress response in hemodialysis (HD). This study comprised the establishment of an animal model for HD and the enrollment of 60 maintenance HD patients. Rats were categorized into control + HD and AS-IV + HD groups, while patients were randomly allocated to control + CCP or AM + CCP groups. In the animal model, Astra-galoside IV (AS-IV), a primary active component of AM, was administered to HD rats to assess dialysis efficiency and examine inflammatory and oxidative stress markers. For patients, assessments of hematological and biochemical parameters, inflammatory and oxidative stress markers, and health-related quality of life (HRQoL) were conducted before and after a 6-month intravenous infusion of AM injection. In the rat model, AS-IV significantly enhanced dialysis efficiency and decreased levels of inflammatory factors and oxidative stress markers compared to the control + HD group. In patients, significant improvements in white blood cell count (WBC), hemoglobin (HGB), hematocrit (HCT), and albumin (ALB) levels in the AM + CCP group after 6 months when compared to the control + CCP group, with the reduced inflammation and oxidative stress response. Additionally, various dimensions of HRQoL showed significant improvements in the AM + CCP group compared to the control + CCP group. Astragalus membranaceus, when integrated into clinical care pathways, holds potential as an adjunctive therapy for individuals undergoing hemodialysis.